A 83-year-old complained of epigastralgia, nausea, vomiting, constipation for two weeks, with a three month history of diffuse pruritus. He also reported colonic diverticulosis and chronic obstructive pulmonary disease with two recent episodes of pneumonia. His medications included beclometasone/formoterolo 100/6 μg delivered via a pressurised metered dose inhaler. He never travelled abroad and he reported a history of farm work since youth.Laboratory tests showed haemoglobin, 96 g/L (normal values 140-180 g/L) and eosinophils 2.2x109 / L (normal count 0-0.5x109 / L). Esophagogastroduodenoscopy showed signs of gastric and duodenal atrophy with petechial lesions. Histological assessment (H&E; x200) showed chronic infiltration with a large amount of eosinophils around numerous helminth forms identified as larvae of Strongyloides stercoralis. The diagnosis of strongyloidiasis was confirmed by indirect immunofluorescence antibody test (titre 1:320). Corticosteroids were discontinued and a single oral dose of ivermectin (200 g/kg) was administered with resolution of symptoms and normalized eosinophil count within 3 months.Clinical Pearls:-• Strongyloidiasis is a soil-transmitted nematode infection, commonly asymptomatic. • The misdiagnosis in a patient chronically treated with corticosteroids, or with any other cause of immunosuppression, can cause a hyperinfection or the more severe disseminated disease which has a case fatality rate close to 100%.Read more here: https://www.ijidonline.com/article/S1201-9712(18)34519-3/pdf